State Life Ins. Corp Of Pak

Please fill out and submit the form below. Our representative will inform you about other requirements for obtaining an insurance policy:

Select Zone:*

Your full name:*

Father’s / husband’s full name:

CNIC No:*

Date of birth:*

Residential address:

Contact No (Res):*

Contact No (Off):*

Contact No (Mobile):

Fax:

Email:*

Your occupation:

Monthly income:*

Choose Plan:

Choose Term:

Supplementary Cover:

If you have selected a joint life plan, please specify the name of other person with relationship to be insured?:

Please state average daily consumption of:

Cigarettes:

Pan/ Niswar:

Alcohol:

Drugs:

Do you have any physical impairment? If yes, please state its nature:

Do you now or ever had heart disease, diabetes, high blood pressure, TB, jaundice or liver, stomach, renal disease, cancer, asthma, epilepsy, nervous or psychological disorders? If so specify with dates:

Are you in good health? If not, describe the nature of ailment:*

Please specify where should our representative call you?*
Home
Office
Mobile

آن لائن پالیسی تجویز

Please fill out and submit the form below. Our representative will inform you about other requirements for obtaining an insurance policy:

Please state average daily consumption of: